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Taking the EHR plunge
Health Data Management Magazine, January 1, 2009
LoCicero Medical Group took two big leaps of faith when it made the transition to electronic health records. The Tampa, Fla.-based practice's four physicians and their staff went cold turkey, shifting from paper records on a Friday to electronic records on a Monday. Plus the practice was a beta site for a start-up firm's software.
But the strategy paid off. Three years into the project, the internal medicine practice has broken even on its $300,000 investment in hardware and software, says Nick Galantino, practice administrator for the clinic, which is anchored by his wife, Karon LoCicero, M.D. Improvements in efficiency, for example, have enabled the practice to increase its revenue 10% annually for three consecutive years by treating more patients each day.
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LoCicero, the practice's medical director, decided to implement electronic records in conjunction with the move to a new office. The practice's sole owner at the start of the automation project, she viewed electronic records as a quality improvement initiative.
"We felt that if we threw out all the paper before the move to the new office, everyone would have no choice but to log in and use the system," Galantino adds.
The practice didn't have to look too far to find its records software. Travis Bond, who owned a dealer that sold the clinic its practice management software, approached the practice about being a beta site for his new records software when he launched his own firm, Bond Technologies.
"What sold me on it was the ease of use," Galantino recalls. "I could stick a user in front of the computer, and if they had experience with the Internet, it was intuitive enough for them to use."
Bond Technologies later was acquired by MediNotes, itself recently acquired by Eclipsys Corp. Atlanta. The latest change in ownership pleases Galantino. He acknowledges he's glad to be doing business now with a larger firm that has staying power.
"When you go with an undercapitalized, small startup company, you run the risk of them going out of business," he says. "We feel fortunate now that the company is part of a larger organization."
The beta experience with Bond Technologies included some headaches, Galantino acknowledges. "I felt like after spending 18 months as a beta site we were on the bleeding edge of technology," he says, pointing to the need to work out bugs in the system with the developers. But the practice was able to work with the vendor to adjust the software to meet its needs.
The biggest challenge, Galantino says, was changing the culture of the office and "getting people comfortable with the fact that everything would be on the computer and nothing on paper."
In fact, one physician left only three months after joining the practice because he struggled with typing and other computer-related tasks. As a result, "we now require new physicians to take a computer competency test under the guise of showing them our electronic records," Galantino says.
Persistent persuasion
The practice administrator says he won over other physicians and staff members with "slow, constant, persistent persuasion."
"We would start group meetings with reinforcement of why we're going to an electronic record," he says.
"To win the support of our physicians, we had to demonstrate that the utilization of electronic records would bolster our accuracy, improve our quality of care and enhance our ease of access to patient health information," LoCicero adds.
"First, our clinicians were trained to use certain functionalities in the software to bolster accuracy. Physicians are able to double-check drug interactions, import pertinent information throughout a patient's record with one simple step and minimize important errors due to sloppy penmanship and misplaced paper records."
In moving to electronic records, the physicians decided that tablet computers would help ease the transition. The practice uses tablets from Motion Computing Inc., Austin, Texas.
LoCicero rejected installing computers in each exam room because of security concerns. "I am able to take the tablet with me when I leave the exam room, so patients cannot gain access to our network in my absence," she says. The use of the tablet allows continuity of one log-in session as opposed to the requirement of multiple login sessions for the use of hardwired PC workstations.
"Much like a paper chart, a tablet affords mobility throughout the office," the physician says.
The practice now has 12 tablet computers as well as 20 docking stations that clinicians use when they want a keyboard or mouse. The devices are linked to a wireless network from D-Link Corp., Fountain Valley, Calif. All data transmissions on the network are encrypted and all users are authenticated to help ensure security.
In addition, physicians can access records from their homes gaining access by using a digital certificate, which verifies their identity.
To get rid of 38,000 paper records, the practice hired temporary staff to scan old charts at a cost of about $60,000. They used two scanners from Fujitsu Ltd., Santa Clara, Calif., to scan 2.5 million pages.
The elimination of paper records meant the practice no longer needed 2,200 square feet of document storage when it moved to its new quarters. It also meant the practice could cut its records staff to 1.5 full-time equivalents from five and make other staff cuts. Today, LoCicero Medical Group has 32 employees, compared with 45 before the automation project.
Doctors now update records using templates and a minimal amount of typing to enter free text. The templates include pick lists of codes to use for filing claims.
Next year, the practice will add a new practice management system from Eclipsys, replacing its old system from Medisoft, now a unit of McKesson Corp.
E-visits
The clinic also has taken the extraordinary step of enabling patients with minor illnesses to conduct e-visits with a nurse practitioner.
Using a portal from RelayHealth, an Atlanta-based unit of McKesson Corp., patients fill out structured templates. As they enter answers, an algorithm kicks in to automatically display other appropriate questions to help simulate a face-to-face encounter with a clinician, Galantino says.
Blue Cross Blue Shield of Florida, Aetna Inc. and CIGNA pay the practice $30 for the online visits. Other patients pay a $30 out-of-pocket fee.
But the online service is off to a slow start, with about 15 e-visits per month. Some 600 patients have registered to use the service, or about 2% of the practice's total.
"By design, we wanted to start out slowly so as not to get overwhelmed," Galantino says. Now, a nurse practitioner is notified on her hand-held computer when new e-mail inquiries arrive via the RelayHealth portal.
The practice pays about $90 per month plus $3 per transaction for the e-visit service. "We're hoping it will cut down on the number of phone calls we get," the practice administrator says. Next year, the practice plans to enable patients to request appointments via the portal.
This month, the practice expects to expand to nine physicians as a result of a merger. So Galantino will have his hands full extending all the practice's technologies to the new clinicians.
LoCicero Medical Group's portal, which features e-visits, is available at www.internal-medicine.com/online-visit.htm.
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